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atoto of Ca{ifar.i..a--Environmental Protection Agency See Instructions an back of p�b, <br /> `arm Approved OMB Na.2050-0039{Expires 9-30-991 Department of Toxic Substances CoM4 <br /> workase print or type. Form designed for nese on elite(12-pitch)lypew r. Sacramento,California <br /> 1. Generator's US EPA GD No. Manifest Document No. 2. Page I Information in the shoded areas <br /> IJNIFORM HAZARDOUS is not required by Federal law. <br /> WASTE MANIFEST C1 Ai T1 O8101012111513181 8 12 10 1$ 9 of 1 <br /> Ia. �rmcat N <br /> 3. Generro <br /> af s Name and Mailing Address urgar2095553 9 5 r � h <br /> 3 <br /> ,sit <br /> PW–MC BELL — <br /> PO BOK 5095, ROC14 #3HOOQ <br /> A. Generator's Phone M. y #MM '(A 945$3 (925)823-8866 <br /> 5. Trans rter 1.C.o1n an Name 6. US EPA ID Number 1 C. In E 7tdttspeSrte Ti lft] f <br /> PPTATION & <br /> lJ. Tionslx,rter`s Pfsane ��.' .. <br /> 6 _ <br /> 7.Trti145p+Yrler 2 Company Name $- US EPA ID Number E, Secs'a yfvt's c,trr`s IP kesc_v xr° <br /> r _ - <br /> F. Tras�sf*nrs¢�s Fha:r¢ d ; <br /> 9: 1 Foc-j _„pme and Site Address , 10. US EPA ID Number G 5teta Tacilrl t IDv�--- - Fri <br /> . c>zfleenta I TecbnologiesRoad <br /> 4 <br /> c <br /> r -.y 12. Contuinoes 13. Tool 1'. Unil 'gx <br /> :{ tr( tion(including Proper Shipping Name,Hazard Class,and ID Number) No. TType Quantity 'WI/vol <br /> 56 LIQUIDS, I.O.S.IUML11K, 01139L), 3x11993 PGII <br /> x(128) Pv f TIT 111316 16 G . <br /> eyQ�er - <br /> Ia� _ <br /> LL _ <br /> a17rs5 ttJ v551or lAat lc is ltsk d Abvv s (( atrogcades for 1f/ds1e3 Li <br /> 1}01 FU11, PI>!SE VA1%1 DIH01 12) a. <br /> — -- - - �� <br /> d. <br /> ntlling Instructions and Additional Information <br /> 1B,rME GILL (800) 917-7701 <br /> s R'S CERTIFICATION: I hereby declare that the contenh of this consignment are Fully and accurately described above by proper shipping name and are classified,packed, <br /> v &nd labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> fi <br /> quantity generator,I certify that I have a progrom in place to reduce the volume and toxicity of waste generated to the degree 1♦ova cloWmined to be economically' <br /> le and efroI I have selected the practicable meth_d aF treatment,siarage,or disposal currently available to me which minimizes the present and future threat to human ltoollh <br /> ith effort to minimize my waste generat on and select the best waste management method that is <br /> svironment;OR,if 1 am a small quantity generator,I have mode a good fa <br /> Yo me and at I can afford. <br /> ... F :Name yr Signature mmonth� Day year <br /> er 1 Acknowledgnment of Receipt of Materials <br /> fVame Signature Month Day Year <br /> 2 Acknowledgement of Receipt of Materials <br /> }`lame SignatureMonth Day Year <br /> x <br /> li`132Yd1'Cy Indication Space <br /> t <br /> 2E4 Eili -Qivn r of O eratnr Certification of receipt of hazardous materials zov ed b rhi i exce t no d in Item 19 <br /> IstQd/T aSigna e Mon Dgy <br /> 4�& <br /> DO NOT WRITE BELOW- THIS INE. <br /> $022A t7/991 White: TSDF SEN 7THIS COPY TO DISC WITHIN 30 DAYS 95812 <br /> 00'-'22 To. P.O. Box 3000, Sacramento, CA <br />